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204 Urogenital and Perineal Trauma

ml in the adolescent or adult. Three films should be obtained: the scout, or vesting season in Africa), crushing and straddle injuries, and sporting
plain, film; an anteroposterior (AP) film; and a postdrainage film. injuries. Instrumentation of the urinary tract with catheters, scopes, and
Penetrating injury sounds may also cause urethral injury, especially in the patient with
underlying urethral stricture. Children with congenital anorectal mal-
Penetrating bladder injuries may result from a pelvic fracture with
formations (high imperforate anus) or girls with disorders of sexual dif-
boney penetration or laceration, gunshot wounds, a stabbing, falls
ferentiation may require surgery that involves the urethra. Prepubertal
onto sharp objects, surgical mishaps (e.g., trochar placement during
girls who sustain a pelvic fracture are four times more likely than adult
laparoscopy), migration or erosion from drains, or manipulation of the
women to have a urethral injury.
umbilical artery catheter in neonates.
Management of Bladder Injuries Classification of Urethral Injuries
Urethral injuries are classified into four grades:
Contusion • Grade I: Contusion. Normal urethrogram.
Most cases of bladder contusion do not need treatment and they usually
have an excellent outcome. Pelvic haematoma may cause difficulty in • Grade II: Stretch injury. Elongation of urethra with extravasation
micturition, and in these patients, catheter drainage is all that is required. of contrast on urethrogram, but with visualisation of the bladder.
These are usually located in the anterior urethra (penile and bulbar
Extraperitoneal rupture portions). See Figure 31.3.
An extraperitoneal rupture accounts for 80% of bladder injuries.
Cystography often reveals a flame-shaped area of contrast extravasa- • Grade III: Partial disruption. Elongation without visualisation of
tion that is confined within the pelvis. In one-fifth of patients, it is bladder on urethrogram. These can occur in either the anterior or
associated with urethral injury as well. posterior urethra (prostatic and membranous portions).
The preferred treatment is urethral catheterisation and drainage • Grade IV: Complete disruption. Complete transection with separa-
alone for a period of about 2 weeks. Tears usually heal completely, tion or extension into the prostate or vagina. In children, complete
even if extensive extravasation has occurred. If laparotomy is done for disruption usually occurs in the posterior urethra between the pros-
associated intraabdominal injuries, the dome of the bladder is opened tatic and membranous portions of the urethra (Figure 31.4).
and the tear repaired without disturbing any pelvic retroperitoneal
haematoma. If the bladder is opened, a temporary suprapubic bladder
catheter should be left in place. Repeat cystography should be
performed prior to removal of the urethral or suprapubic catheter.
Intraperitoneal rupture
An intraperitoneal rupture occurs mainly at the dome of the bladder
and is usually due to a direct blow to the distended bladder or a sudden
deceleration injury. Contrast may be seen within the peritoneal cavity
outlining the intestines.
Intraperitoneal rupture occurs more commonly in children than
adults. Thus, early operative repair is the treatment of choice for
children because the presence of urine in the peritoneal cavity can lead
to life-threatening metabolic and infectious problems.
10
Operative Details
The bladder is approached through a lower abdominal incision.
One must carefully inspect the ureteral orifices and bladder neck.
Overlooking an injury in these areas may result in ureteral obstruction,
sepsis, and/or incontinence. An extraperitoneal tear is closed from with- Figure 31.3: Retrograde urethrogram showing grade II urethral stretch injury
in the bladder by using absorbable sutures, taking care to avoid occlu- with extravasation of contrast.
sion of the ureteric orifices. Suprapubic bladder drainage is maintained
for 7–10 days and removed once the cystogram has shown resolution
of the extravasation. The peritoneum is drained by using a closed suc-
tion drain. The drain is removed when the patient is voiding normally.
Penetrating Injuries
Penetrating injuries of the bladder are managed by laparotomy due to
the high incidence of associated injury to other organs. These bladder
injuries are often more extensive than seen on radiographic images.
Meticulous debridement and dual layer closure of the bladder are key
to a successful outcome. If there is also a bowel injury, a flap of omen-
tum should be placed over the bladder repair to prevent formation of a
fistula. After thorough debridement of the injury and bladder closure,
a suprapubic bladder catheter is left in place and the perivesical area is
drained by closed suction drain.
Urethral Injury
Urethral injuries in children can occur as a result of blunt or penetrating
trauma to the abdomen, pelvis, and perineum. Blunt trauma with pelvic
fracture accounts for most posterior urethral injuries in children. The
mechanism of most of these types of injuries include motor vehicle Figure 31.4: Retrograde urethrogram after pelvic fracture showing complete
urethral disruption.
accidents, falls from heights (commonly occurring during fruit har-